Several of my graduate students came to class wanting to talk about
diagnosis and the all-pervasive use of the DSM-IV. They expressed their
discomfort with using the manual, and they felt that their work settings
put too much emphasis on diagnostics. As fledgling counselors, they
feared that by relying too heavily on the manual they would be
"missing the forest for the trees." Their concerns became the
focus of discussion for our weekly meeting.

The Diagnostic and Statistical Manual of Mental Disorders is a
virtual bible of the mental health professions, as well as the primary
reference work used for insurance reimbursement. Like it or not, the
manual's contents are ingrained in the minds of clinicians. The
DSM-IV defines disorders, and in so doing, defines our norms. The next
edition, DSM-V, is scheduled to appear sometime in 2012-2013. A panel of
psychologists and psychiatrists have been appointed to add to, delete,
or maintain current diagnostic categories.

The fact that diagnoses can be removed or added reminds us that
these categories are constantly reconstructed. For example, the second
edition of the DSM listed homosexuality as a mental disorder. In 1973,
the American Psychiatric Association voted to no longer list
homosexuality as a disorder. Fourteen years later, in 1987, the American
Psychological Association removed all references to homosexuality as a
diagnostic issue. Each new generation of clinicians who are charged with
the task of revising the manual are products of a discrete historical
context and bring with them the values and biases of the age in which
they live.

Our assumption that the manual is a scientific classification
system needs to be challenged. In truth, the diagnostic manual describes
symptoms and not underlying causes. Symptoms can be ordered and
organized in various ways depending on the perceptions of the clinician.
There is some truth in the old cliche that no two clinicians will offer
the same diagnosis without some variations on a theme.

In this age of evidence-based practice, diagnostics has taken an
important place in the counseling profession. My students question
whether or not putting a diagnostic label on a client helps. A student
reported that one of her clients uses her diagnosis as an excuse for not
taking responsibility for her behavior. The client said, 'Tm
bipolar; there's nothing I can do." Another student reported
that his client has reduced himself to the diagnosis and now derives his
identity from being "manic." Yet another student reported that
the moment that she reads the intake and scans down to the diagnosis,
she finds herself influenced by what she reads and she fears that she
comes into the sessions with bias.

As a counselor educator, my goal is to help students learn to
balance the heavy emphasis placed upon diagnostics with a wellness model
that focuses on the strength and resiliency of the client. I encourage
students to remember that they are working with a person and not a
diagnosis. I challenge them to stay mindful of their biases and
assumptions and not to fall into the trap of self-fulfilling prophesies.

As new theories, practices, and research studies proliferate, we
sometimes forget what is at the heart of the counseling endeavor: the
client, warts and all. Diagnostics is useful only if it helps us to work
more effectively with our clients. Otherwise, we need to be vigilant
against letting ourselves get carried away with a lot of confected,
professional jargon to explain away very real problems in living.

By Irene Rosenberg-Javors, MEd, LMHC, DAPA

Irene Rosenberg-Javors, MEd, is a Diplomate of the American
Psychotherapy Association, a licensed mental health counselor, and a
psychotherapist in New York City. She is also adjunct associate
professor of mental health counseling in the Mental Health Counseling
Program of the Ferkauf Graduate School of Psychology at Yeshiva
University. She can be reached at ijavors@gmail.com.